Provider Demographics
NPI:1720122203
Name:VINES, DEREK GAVIN (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:GAVIN
Last Name:VINES
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:SUITE 3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 W. GRANT ST. STUDENT WELLNESS CENTER
Practice Address - Street 2:MEDICAL SERVICES, SUITE 2200
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59717
Practice Address - Country:US
Practice Address - Phone:406-994-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry